Validation of the Ask Suicide-Screening Questions with Adolescents in Primary Care

Background: Pediatric primary care patients are at increased risk for suicide. Ninety percent of youth with suicidal ideation, plan or intent were seen by a primary care provider within the previous year. Early detection of suicide risk is a critical prevention strategy. Given the potential for screening to improve outcomes, primary care providers have enormous potential to prevent suicides and connect young patients to needed mental health care. Screening can be effective, but is an under-utilized prevention strategy. Primary care providers often lack the training and capacity to implement suicide risk screening in their practices, due to discomfort, stigma, and lack of brief screening tools that have been validated in primary care. Validation of suicide risk screening tools and guidelines for implementation can be effective ways to identify patients at risk and to link them to specialty care. This study builds on previous research conducted with the Ask Suicide-Screening Questions (ASQ), a 4-item brief suicide risk screening instrument that has been validated in pediatric emergency settings. Given the 2016 Joint Commission Sentinel Event Alert, hospitals have been implementing the ASQ in inpatient and outpatient medical settings; however, validation data from the primary care setting has not yet been examined. The aim of this study is to validate the Ask Suicide-Screening Questions in a pediatric primary care setting.

Methods: This is a cross-sectional instrument validation study that took place at an urban, primary care clinic associated with a tertiary care teaching hospital. A convenience sample of 153 patients aged 10-19 years who presented to primary care during data collection weeks were administered the ASQ and the criterion standard, Suicidal Ideation Questionnaire [SIQ] or Suicidal Ideation Questionnaire- Junior [SIQ-Jr.], a brief depression scale (the Patient Health Questionnaire- Modified for Adolescents [PHQ-A]), and a clinical and demographic questionnaire.

Results: A total of 155 patients were screened. 25 of the patients (16%) were at elevated suicide risk on the ASQ and 7 of the patients (4.5%) were at elevated suicide risk on the SIQ/SIQ- Jr. Fifty-seven percent (N=88) of the sample was female, the average age was 16.93 (SD: 1.98) and the sample was diverse: 33% Black, 32% Latino, 17% White, 10% other and 8% Asian/Pacific Islander. The ASQ had a sensitivity of 100% (7/7) (95% CI= 59.0, 100), specificity of 88% (130/148) (95% CI= 81.4, 92.6), and a negative predictive value of 100% (130/130) (95% CI 97.2, 100).

Conclusions: A 4-question screening instrument, the Ask Suicide-Screening Questions (ASQ), with high sensitivity and negative predictive value in primary care, can accurately detect clinically significant suicide risk amongst adolescents presenting to primary care.